A Collection of Problems with the US Health Care System

Pediatrician/Former Medical Director. New York. Statement 10011.

Categories: Insurance Professional Statements
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The land mines facing any medical director:

  • Benefits restriction. In one of my plans we had regular meetings to determine what our highest costs were and how we could redesign benefits to control them).
  • Exclusions, even those fabricated to justify a trend in denials.
  • Pre-existing condition exclusions, to ensure that persons with known conditions would either forgo our plan, or give us the mechanism to avoid payment for services, creating a game of wits to figure out ways to make current needs connect with some prior diagnosis.
  • Selective marketing using partial information, e.g., about coverage limits and rules of the health plan.
  • Underwriting, or selection of the ‘best’ groups,. (I became a veritable ‘bookie’ for the plan).
  • Contract design and implicit restraint of trade; we would exploit a physician’s economic vulnerability by telling them they could either sign or be excluded.
  • Maze of rules and hoops for authorizations, referrals and network availability — convoluted procedures set out in a ‘Certificate of Coverage’ that became grounds for denial of payment.
  • Claims of authority that exacted a desired economic outcome, again with implied threats to de-selection; and finally
  • The “smart bomb” for “cost-containment: “medical necessity” denials that employ non-standard criteria, oftentimes developed without sufficient specialty-specific expertise to be durable’ this is the ultimate weapon for the plan.